NDD 10603

NDD 10603
LECTURE 6:TODDLER AND
PRESCHOOLER NUTRITION
DR. SHARIFAH WAJIHAH WAFA BTE SST WAFA
School of Nutrition and Dietetics
Faculty of Health Sciences
sharifahwajihah@unisza.edu.my
KNOWLEDGE FOR THE BENEFIT OF HUMANITY

Key Nutrition Concepts
continue to grow
and develop
Physically
Cognitively
Emotionally
New skills rapidly
with time

innate ability to self-regulate food intake
Parents & caretakers provide nutritious
foods
children decide if & how much to eat

Parents & caretakers
tremendous influence

Toddlers
1-3 years (12-36
months)
Increase in fine
motor skills
Rapid increases in
gross motor skills

Preschool age
3-5 years of age
(Begin Kindergarten)
increasing autonomy
broader social
circumstances
increasing language
skills
expanding self-
control of behavior

Physical growth
 Decrease in rate
 Body proportions change – head growth is
minimal ; trunk & limbs lengthen
 Fat proportions decrease
 Catch-up growth can occur

Developmental connections to
nutrition: toddlers
Initial neophobia
reluctance to eat, or the avoidance of, new
foods.
Exerting independence
imitation

Developmental connections:
preschoolers
Egocentrism
Cooperation socially
Control –
language
Start to limit behavior internally

Importance of nutrition status
adequate energy & nutrients
Undernutrition
FTT & cognitive impairment

SCHOOL OF NUTRITION AND DIETETICS . FACULTY OF HEALTH
SCIENCES
Normal Growth and Development
 Infants triple birth weight
in first 12 months, but
growth slows after that
 Toddlers gain 0.2 kg and
1 cm per month
 Preschoolers gain 2.0kg
and 7cm per year
 Decrease in growth rate
accompanied by
decrease in appetite and
food intake

SCIENCES
Monitoring Children’s Growth
 Use calibrated scales &
height board
 Toddlers under age 2
years
 Weighed without clothes or
diaper
 Determine recumbent
length
 Children over age 2 years
 Weighed with light clothing
 Measure stature with no
shoes

SCIENCES
WHO Growth Standards
 WHO (World Health Organization) published growth standards for
children from birth to 5 years.
 International growth standards regardless of ethnicity or
socioeconomic status.

SCIENCES
WHO Growth Standards
 Gender-specific
 Health care professional can
plot and monitor:
 Length/height-for-age
 Weight-for-age
 Weight-for-length/height
 Body mass index-for-age
(BMI-for-age)
 Head circumference-for-age
 Arm circumference-for-age
 Subscapular skinfold-for-age
 Triceps skinfold-for-age

SCIENCES

Interpreting the BMI
Underweight: BMI/age <5%tile
Normal: BMI for age 5-85%tile
At risk of overweight: BMI for age 85-
95%tile
Overweight: BMI for age>95%tile

SCIENCES
Common Problems with Measuring
& Plotting Growth Data
 Error in measuring may result in errors in health
status assessment
 Use of calibrated equipment and plotting
accuracy are vital

Recumbent length
Not my husband 

Head Circumference
Not my baby 

Physiological and Cognitive
Development
Development of feeding skills
Feeding behaviors
Appetite and food intake
Growth

SCIENCES
Physiological Development - Toddlers
 A time of expanding physical
and developmental skills
 Walking begins as a “toddle,”
improving in balance &
agility
 Progress by month
 15—crawl upstairs
 18—run stiffly
 24—walk up stairs one foot
at a time
 30—alternate feet going up
stairs
 36—ride a tricycle

SCIENCES
Cognitive Development- Toddlers
 Toddlers “orbit” around
parents
 Transitions from self-
centered to more interactive
 Vocabulary expands:
 10-15 words at 18 months
 100 at 2 years
 3-word sentences by 3
years
 Temper tantrums common
(the terrible two’s)

SCIENCES
Cognitive Development -Preschooler
 Egocentric—cannot
accept another’s point of
view
 Learning to set limits for
himself
 Cooperative & organized
group play
 Vocabulary expands to
>2000 words
 Begins using complete
sentences

Feeding skills: toddlers
 Weaning
 Ability to chew and
self feed
 “I do it”
 Prefer to eat with
hands
 Can use cups and
spoons
 Food jags: strong
food preferences
and dislikes
 Food refusals
 Natural to have
decreased interest in
food

SCIENCES
 “Food jags” –
prolonged periods of
refusing a particular food
or foods they previously
liked
 To circumvent food jags:
 Serve new foods along
with familiar foods
 Serve new foods when
child is hungry
 Other family members
should eat the new foods
in front of toddler
Feeding skills: toddlers

Feeding skills: Preschoolers
 Skilled with fork,
spoon, cup
 Tolerates most
textures of foods
 Must be careful of
choking hazards
 Messy eating is not
the norm
 Growth
variable….appetite
and intake increase
prior to growth spurt
 Desire to help and
please
 May be picky –
exerting control,
comforted by familiar
foods

SCIENCES
 Can use a fork,
spoon, & cup
 Spills occur less
frequently
 Foods should be cut
into bite-size pieces
 Adult supervision still
required
Feeding skills: Preschoolers

Energy and Nutrient Needs
Energy needs
Protein
Vitamins and minerals

Toddlers
Macronutrients:
Estimated energy requirement (EER) is
kcal/day = (89 x weight(kg)-100)+20
DRI 992-1046 kcal
30%-40% of total kcal from fat
1.1 grams of protein per kg body weight
130 g carbohydrates per day
14 grams fiber per 1,000 kcal/day

Toddlers
Micronutrients:
 fruits and vegetables
 Vitamins A, C, E, calcium, iron, zinc
Iron deficient anemia

Toddlers
Fluid needs:
1.3 liters per day
Supplements:
fluoride via fluoridated water
Supplements ???
 If giving supplements, should not exceed 100%
RDA for any nutrient

Toddlers
Allergies:
watch for food allergies
introduce one new food at a time
Vegetarian families:
including eggs and dairy can be a healthful
diet
A vegan diet may lack essential vitamins
and minerals

Preschoolers
Macronutrients:
Energy – 1642-2279 depending on gender
and age
Total fat intake should gradually drop to a
level closer to adult fat intake
 25%-35% of total energy from fat
0.95 grams protein per kg body weight
130 grams carbohydrate per day
14 grams fiber per 1,000 kcal

Preschoolers
Micronutrients:
Vitamins and minerals
 fruits and vegetables continue to be a concern
 Vitamins A, C, E, calcium, iron, zinc
AI of calcium increases for toddlers
RDAs for iron and zinc also increase

Preschoolers
Fluid:
1.7 liters per day
Supplements:
?????
May be recommended when particular food
groups are not eaten regularly
Supplements should be appropriate for the
child’s age

Vitamin and mineral supplements
Not strictly necessary
May be beneficial when entire food
groups are not consumed with regularity
Should be age specific
Monitor UL
At risk children: abused or neglected;
anorexia; fad diets; vegan diet

How much food intake?
 Toddlers – 1 T food per
year of age
 Caregivers tend to
overestimate portion
sizes
 Important to establish
regular (yet flexible)
patterns
 Avoid uncontrolled
grazing
 Serve child sized
portions
 Avoid mixing foods
together
 Again, regular but
flexible patterns
 Avoid uncontrolled
grazing

SCIENCES
 Mealtime an opportunity
for parents to model
healthy eating
behaviors, toddlers to
practice language and
social skills, develop
positive self-image
 Not the time for
battles or “force
feedings”
Mealtime

Other Factors
Temperament differences
40% easy, 10% difficult, 15% slow-to-warm-
up
Food preference development

Food Preference Development
 a complex process
 Influences
 Genetics
 Parents
 Media
 educators at school
*By age 3, the dislike for certain foods has already
developed.*

Biological Influence
 Genetic pre-
disposition of tastes
 Food Neophobia
 Exposure
 After-meal results
 Self-Regulation
 Developmental
Landmarks
 Cognitive
Development

Parental & Familial Influence
 Economics &
Geography
 Nutrition Knowledge
 Foods Consumed
During Pregnancy
 Food Modeling
 Short-Order Cooking
 Restriction

Implications for Practice
1. Exposure
2. Target Children’s Literature
3. Learning across the curriculum
4. Pregnancy Books
5. Family Meals
6. Proper Influence

Most common nutrition problems
Iron-deficiency anemia
Dental caries
fluoride
Constipation
Lead poisoning
Food Security
Food Safety

Diagnostic levels
1-2 years of age: Hgb<11 g/dl; Hct
<32.9%
2-5 years: Hgb <11.1 g/dl; Hct <33%

Prevention
7-10 mg iron/day
Milk intake – should meet calcium needs
but not replace iron rich foods.
Max. 24 oz/day

SCIENCES
Dental Caries
 Prevalence:
 1 in 5 children ages 2 to 4
 Causes:
 Bedtime bottle with juice or milk
 Streptococcus mutans
 Sticky carbohydrate foods
 Prevention:
 Fluoride—supplemental amounts vary by age &
fluoride content of water supply

SCIENCES
Constipation
Definition: Hard, dry stools associated
with painful bowel movements
Causes: “Stool holding” and diet
Prevention: Adequate fiber

Lead
Exposure
old paint, pieces of metal, lead pipes
leaching into water ;soil; imported canned
foods; household dust;
5-10x higher rate of absorption
Other nutrient deficiencies exacerbate
vitamin c, iron, calcium, Vitamin D, zinc
3x more likely to have elevated lead levels

Lead
Seen in ~2.2% of children ages 1-5
Low levels of lead exposure linked to
lower IQ & behavioral problems
High blood lead levels may decrease
growth
Reduce lead poisoning by eliminating
sources of lead

The signs and symptoms of lead poisoning in
children are nonspecific and may include:
 Irritability
 Loss of appetite
 Weight loss
 Sluggishness
 Abdominal pain
 Vomiting
 Constipation
 Pallor from anemia

Complications of lead contamination
 Nervous system and kidney damage
 Learning disabilities
 Speech, language and behavior problems
 Poor muscle coordination
 Decreased muscle and bone growth
 Hearing damage

Treatment
Removal of source
chelation

SCIENCES
Dietary and Physical Activity
Recommendations
Dietary guidelines
Offer a variety of foods, limiting foods high in
fat & sugar
60 minutes of vigorous physical activity each
day
MyPyramid developed by the USDA for
young children

Other Concerns
Food allergies and intolerance
Dietary supplements and herbal
remedies
Sources of nutrition services

Food Allergies and Intolerance
 True food allergies seen in ~2% to 8% of
children
 Common food allergies include:
 Milk
 Eggs
 Wheat
 Peanuts
 Walnuts
 Soy
 Shellfish

Dietary Supplements and Herbal
Remedies
Parents should be cautioned about use
of supplements and/or herbs to treat
various conditions
Often unproven recommendations come
from parent coalitions and advocacy
groups

Sources of Nutrition Services
 State programs
 Early intervention programs
 Early childhood education programs (IDEA)
 Head Start
 Early Head Start
 WIC
 Low birthweight follow up
 Child care feeding programs

Growth Assessment
 Nutrition assessment should be first step to
determine if nutrition services are needed
 Assessment answers the following:
 Is child’s growth on track?
 Is child’s food and nutrient intake adequate?
 Are feeding or eating skills age appropriate?
 Does diagnosis affect nutritional needs?

Growth Assessment
Interpretation of growth charts should
consider special health condition
Growth charts specific to some
conditions include:
LBW or VLBW
Special head growth chart

Feeding Problems
 Special health care needs cause feeding
problems in young children combined with
typical feeding issues of the average toddler or
preschooler
 Examples include:
Low interest in eating
Long mealtimes
Preferring liquids over solids
Food refusals

Behavioral Feeding Problems
 Mealtime feeding problems are common with
toddlers & preschoolers with behavioral &
attention disorders
 Behavioral disorders that affect nutritional
status
Autism Spectrum Disorder (ASD)
Attention deficit hyperactivity disorder
(ADHD)
 May be suspected in preschool years but usually
treated in the school years

Other Feeding Problems
Excessive fluid intake
Child would rather drink than eat
Feeding problems & food safety
Mashed or pureed foods and tubing or
devices for feeding may be contaminated or
spoilage may occur
Feeding problems from disabilities
involving neuro-muscular control

Nutrition-Related Conditions
Failure to thrive (FTT)
Toddler diarrhea & celiac disease
Autism Spectrum Disorders
Muscle coordination problems & cerebral
palsy
Pulmonary problems
Developmental delay & evaluations

Failure to Thrive (FTT)
Inadequate wt or ht gain with growth
declines more than 2 growth percentiles
May result from:
Digestive problems
Asthma or breathing problems
Neurological conditions
Pediatric AIDS
Recovery can include catch-up growth

Toddler Diarrhea and Celiac
Disease
“Toddler diarrhea” typically caused by
sucrose & sorbitol content of fruit juices
Limiting juice may be recommended
Celiac disease results in diarrhea &
caused by sensitivity to the protein
gluten found in wheat & other grains
Complete restriction of any gluten-
containing foods

Autism Spectrum Disorders
No specific diet is recommended for
prevention or treatment
Gluten-free & casein-free diets have
been used by parents but not endorsed
by professional societies

Muscle Coordination Problems &
Cerebral Palsy
 Cerebral palsy
 Group of disorders characterized by impaired
muscle activity & coordination present at birth or
developed during early childhood
 Spastic quadriplegia: a form of cerebral palsy
 Reduced dietary intake results from child easily
becoming tired while eating
 Meal pattern may be changed to provide small, frequent
meals, and snacks to prevent tiredness at meals
 Foods recommended are easy to chew and soft

Pulmonary Problems
 Examples of pulmonary (breathing) problems
are brochopulmonary dysplasia & asthma
 Breathing problems increase nutrient needs,
lower interest in eating & can slow growth
 Preterm infants at high risk of breathing
problems
 Recommend small, frequent meals with
concentrated energy

Developmental Delay & Evaluation
Developmental delay may be suspected
when:
Specific nutrients are inadequately or
excessively consumed
May result from iron deficiency or lead
toxicity
Physical growth may be impacted

NDD 10603

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